Geriatric Assessment: An Office-Based Approach
Am Fam Physician. 2018 Jun 15;97(12):776-784.
Author disclosure: No relevant financial affiliations.
Family physicians should be proficient in geriatric assessment because, as society ages, older adults will constitute an increasing proportion of patients. Geriatric assessment evaluates medical, social, and environmental factors that influence overall well-being, and addresses functional status, fall risk, medication review, nutrition, vision, hearing, cognition, mood, and toileting. The Medicare Annual Wellness Visit includes the key elements of geriatric assessment performed by family physicians. Comprehensive geriatric assessment can lead to early recognition of problems that impair quality of life by identifying areas for focused intervention, but a rolling geriatric assessment over several visits can also effectively identify subtle or hidden problems. Assessment should be tailored to patient goals of care and life expectancy. By asking patients and families to self-assess risks using precompleted forms, and by using trained office staff to complete validated assessment tools, family physicians can maximize efficiency by focusing on identified problems. Fall risk can be assessed with a single screening question: “Have you fallen in the past year?” The Beers, STOPP (screening tool of older persons' prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources for reviewing the appropriateness of medications in older adults. Screening for depression is recommended when depression care supports are available; this can be performed with a brief two-item screen, the Patient Health Questionnaire-2. Older adults should be screened for unintentional weight loss and malnutrition. Although rates of hearing loss and vision loss increase with age, there is insufficient evidence to recommend screening in asymptomatic individuals. The U.S. Preventive Services Task Force advises clinicians to assess cognition when there is suspicion of impairment. Urinary incontinence can impair patients' quality of life, and it can be assessed with a two-question screening tool. Immunizations and advance care planning are also important components of the geriatric assessment.
Older adults with complex chronic conditions will be an increasing proportion of family physicians' patient population. In 2015, patients older than 65 years accounted for 31% of all U.S. office visits, and that proportion will grow.1 Since 2013, every day 10,000 baby boomers turn 65 years of age and enter Medicare.2 By 2030, the population older than 65 years will double to 72 million (20% of the total U.S. population).2 Individuals are living longer, with multiple chronic illnesses, making them vulnerable to disability and diminished quality of life. Although 95% of older patients with complex needs have regular access to care, 58% struggle to navigate the system, and 62% are stressed about their ability to afford housing, utilities, or meals.3 Geriatric assessment, which evaluates medical problems; cognitive, affective, and functional abilities; and social and environmental factors, can identify these unrecognized needs to improve the well-being of older adults.
Evidence Base for Comprehensive Geriatric Assessment
Most of the literature supporting geriatric assessment models involves specialized geriatric team-based assessment. Comprehensive geriatric assessment is a systematic evaluation of frail older persons by a team of health professionals and consists of six core components: data gathering, team discussion, development of a treatment plan, and implementation of a treatment plan, with monitoring and revision as needed.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
Physicians should screen older patients for a risk of future falls using a single question, “Have you fallen in the past year?” In-depth, multifactorial risk assessment for falls should be reserved for patients who respond affirmatively or those who take longer than 12 seconds to perform a Timed Up and Go Test.
Older adults should be screened for depression when appropriate support measures are available to ensure accurate diagnosis, effective treatment, and follow-up.
There is insufficient evidence to recommend screening for hearing loss in asymptomatic adults older than 50 years. Targeted screening should be performed in those with perceived hearing loss, and cognitive and affective symptoms.
Targeted screening for cognitive impairment is appropriate for patients with suspected impairment. The Mini-Cog tool is effective in primary care and appropriate for trained staff to
Referencesshow all references
1. Rui P, Okeyode T. National Ambulatory Medical Care Survey: 2015 state and national summary tables. Atlanta, Ga.: National Center for Health Statistics, Centers for Disease Control and Prevention; 2015. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2015_namcs_web_tables.pdf. Accessed February 25, 2018....
2. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, Ga.: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2013. https://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf. Accessed February 24, 2017.
3. Ryan J, et al. How high-need patients experience health care in the United States: findings from the 2016 Commonwealth Fund Survey of High-Need Patients. New York, NY: The Commonwealth Fund; 2016. http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2016/dec/1919_ryan_high_need_patient_experience_hnhc_survey_ib_v2.pdf. Accessed February 24, 2017.
4. Reuben DB, Rosen S, Schickedanz HB. Principles of geriatric assessment. In: Halter JB, Ouslander JG, Studenski S, et al., eds. Hazzard's Geriatric Medicine and Gerontology. 7th ed. New York, NY: McGraw-Hill Education; 2016: 157–170.
5. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;(9):CD006211.
6. Sternberg SA, Bentur N. The contribution of comprehensive geriatric assessment to primary care physicians. Isr J Health Policy Res. 2014;3(1):44.
7. Centers for Medicare and Medicaid Services; Medicare Learning Network. The ABCs of the Annual Wellness Visit (AWV). https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf. Accessed February 24, 2017.
8. American Geriatrics Society and Talebreza S, ed. Geriatrics Evaluation and Management Tools. New York, NY: American Geriatrics Society; 2016. https://geriatricscareonline.org/ProductAbstract/geriatrics-evaluation-management-tools/B007#. Accessed March 27, 2018.
9. Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged ≥65 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(37):993–998.
10. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA. 2007;297(1):77–86.
11. American Academy of Family Physicians. Clinical preventive service recommendation. Fall prevention in older adults. 2012. https://www.aafp.org/patient-care/clinical-recommendations/all/fall-prevention.html. Accessed August 14, 2017.
12. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50–58.
13. Centers for Disease Control and Prevention; National Center for Injury Prevention and Control. Timed Up & Go (TUG). https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf. Accessed August 31, 2017.
14. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go test.” Arch Phys Med Rehabil. 1986;67(6):387–389.
15. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148–157.
16. US Preventive Services Task Force. Draft update summary: falls prevention in community-dwelling older adults: interventions. U.S. Preventive Services Task Force. Rockville, Md.: Agency for Healthcare Research and Quality; 2017. https://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement/falls-prevention-in-older-adults-interventions1. Accessed March 27, 2018.
17. Choosing Wisely. American Geriatrics Society. Don't prescribe a medication without conducting a drug regimen review. 2014. http://www.choosingwisely.org/clinician-lists/american-geriatrics-society-drug-regimen-review/. Accessed March 7, 2017.
18. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. 2015. http://geriatricscareonline.org/toc/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001. Accessed March 7, 2017.
19. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–218.
20. Rodda J, Walker Z, Carter J. Depression in older adults. BMJ. 2011;343:d5219.
21. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380–387.
22. American Academy of Family Physicians. Clinical preventive service recommendation. Depression. 2016. https://www.aafp.org/patient-care/clinical-recommendations/all/depression.html. Accessed August 14, 2017.
23. Thibault JM, Steiner RW. Efficient identification of adults with depression and dementia. Am Fam Physician. 2004;70(6):1101–1110.
24. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
25. Yang Y, Brown CJ, Burgio KL, et al. Undernutrition at baseline and health services utilization and mortality over a 1-year period in older adults receiving Medicare home health services. J Am Med Dir Assoc. 2011;12(4):287–294.
26. Winter JE, MacInnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: a meta-analysis. Am J Clin Nutr. 2014;99(4):875–890.
27. Choosing Wisely. American Geriatrics Society. Ten things clinicians and patients should question. 2015. http://www.choosingwisely.org/societies/american-geriatrics-society/. Accessed March 9, 2017.
28. Chou R, Dana T, Bougatsos C, Fleming C, Beil T. Screening adults aged 50 years or older for hearing loss: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;154(5):347–355.
29. Lin FR, Metter EJ, O'Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol. 2011;68(2):214–220.
30. American Academy of Family Physicians. Clinical preventive service recommendation. Hearing, screening loss in older adults. 2012. https://www.aafp.org/patient-care/clinical-recommendations/all/hearing.html. Accessed August 14, 2017.
31. Chou R, Dana T, Bougatsos C, Grusing S, Blazina I. Screening for Impaired Visual Acuity in Older Adults: A Systematic Review to Update the 2009 U.S. Preventive Services Task Force Recommendation. Evidence synthesis no. 127. AHRQ publication no. 14-05209-EF-1. Rockville, Md.: Agency for Healthcare Research and Quality; 2016.
32. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for impaired visual acuity in older adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(9):908–914.
33. American Academy of Family Physicians. Clinical preventive service recommendation. Visual difficulties and impairment. 2016. https://www.aafp.org/patient-care/clinical-recommendations/all/visual.html. Accessed August 14, 2017.
34. Cordell CB, Borson S, Boustani M, et al.; Medicare Detection of Cognitive Impairment Workgroup. Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9(2):141–150.
35. Moyer VA; U.S. Preventive Services Task Force. Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(11):791–797.
36. American Academy of Family Physicians. Clinical preventive service recommendation. Dementia. 2014. https://www.aafp.org/patient-care/clinical-recommendations/all/dementia.html. Accessed August 14, 2017.
37. Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry. 2006;21(4):349–355.
38. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–1454.
39. Song D, Yu DS, Li PW, Lei Y. The effectiveness of physical exercise on cognitive and psychological outcomes in individuals with mild cognitive impairment: a systematic review and meta-analysis. Int J Nurs Stud. 2018;79:155–164.
40. Gorina Y, Schappert S, Bercovitz A, Elgaddal N, Kramarow E. Prevalence of incontinence among older Americans. Vital Health Stat 3. 2014;(36):1–33.
41. Moore AA, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. Am J Med. 1996;100(4):438–443.
42. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines. MMWR Recomm Rep. 2016;65(5):1–54.
43. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older - Advisory Committee on Immunization Practices (ACIP), 2012 [published correction appears in MMWR Morb Mortal Wkly Rep. 2012; 61(27): 515]. MMWR Morb Mortal Wkly Rep. 2012;61(25):468–470.
44. Tomczyk S, Bennett NM, Stoecker C, et al.; Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2014;63(37):822–825.
45. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep. 2018;67:103–108.
46. Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am. 2015;99(2):391–403.
47. Austin CA, Mohottige D, Sudore RL, Smith AK, Hanson LC. Tools to promote shared decision making in serious illness: a systematic review. JAMA Intern Med. 2015;175(7):1213–1221.
48. Sudore RL, Barnes DE, Le GM, et al. Improving advance care planning for English-speaking and Spanish-speaking older adults: study protocol for the PREPARE randomised controlled trial. BMJ Open. 2016;6(7):e011705.
49. Elsawy B, Higgins KE. The geriatric assessment. Am Fam Physician. 2011;83(1):48–56.
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